NECK LIFT: TREATMENT OPTIONS
WHY PERFORM A NECK LIFT?
A well-contoured neck is imperative to an attractive and appealing appearance. A good neck line conveys a sense of youth and vitality, and lends an appearance of sensuality and beauty. Neck improvement is of high priority to almost every patient seeking facial harmony and rejuvenation, and the results of facelift procedures are largely judged by the outcome achieved in the neck. If the neck is not sufficiently improved, patients are usually dissatisfied with the outcome.
HOW SHOULD A NECK LIFT BE PERFORMED?
It is unlikely there will ever be a consensus on how a neck lift should be performed and it is a fact that no one procedure will be suitable for all patients. The technique used cannot be arbitrary, will depend on deformities present, and will vary from patient to patient. A positive outcome relies on the diagnosis of problems and the application of a sound surgical plan, and any surgeon capable of identifying patient problems and formulating a logical plan for their correction can achieve excellent outcomes.
So how should one perform a neck lift? Perhaps it is easiest to start by stating what not to do. Despite the fact that it is a common practice, it is not enough to perform submittal liposuction and tighten the skin as such an approach ignores a number of anatomical and developmental problems present in many patients seeking neck improvement. Removing subcutaneous fat and tightening the skin over these problems does not correct them, and the presence or absence of each must be looked for in order to create an apply an appropriate surgical plan.
Patients seeking neck improvement have a range of options available to them depending on the problems present, the degree of improvement they seek, and the time, trouble and expense they are willing to undergo to obtain the improvement they desire. And while it is incumbent upon us to discuss these options and the advantages and disadvantages of each, patients are also seeking our guidance as to what is possible, what is practical, and what is really best. It is not enough to steer patients to procedures we are comfortable with. We are professionally bound and ethically obliged to refer patients for the care they need and desire if we are not able to provide it ourselves.
WHY IS SUBMITTAL LIPOSUCTION NEVER A GOOD IDEA?
Submental liposuction is the simplest and likely the most commonly performed procedure to improve neck contour in the range of options available to patients. It does not constitute a true neck lift, however, and only occasionally produces optimal outcomes. Patients and surgeons are predictably drawn into a sense of detail of this by the fact that submental liposuction will occasionally produce worthwhile improvement, and it is these atypical outcomes that are predictably displayed in offices, placed in advertisements, shown on TV and websites, published in the beauty press, and even included in presentations at plastic surgery symposia. Adding to the deception is the fact that these photographs have usually been taken int he early postoperative period when swelling is still present, which obscures irregularities and underlying but untreated deep layer problems. In reality, submental liposuction is an incomplete solution to neck problems for most patients.
‘SHORT-SCAR’ NECK LIFT (NECK LIFT WITH SUBMENTAL INCISION ONLY)
Although submental liposuction alone will rarely produce optimal neck improvement, a neck lift performed through a submental incision without any removal of skin can create attractive cervical contour in many patients. This is due to the fact that, unlike liposuction, a neck lift performed through a submental incision allows deep layer problems and platysmal laxity typically present in the majority of patients seeking neck improvement to be addressed. This, however, begs the question, how can good neck contour be created without removing and tightening the skin, and what happens to the ‘excess’ skin if only the deeper layer treatment is made and no skin is excised? The answer to this question is twofold: First, it is important to appreciate that in a properly performed neck lift contour is created by modification of deep layers of the neck, not by tightening the skin. Skin is intended to be a covering layer and serve a covering function. It is meant to stretch and give as we move and express ourselves. It is not intended to be a structural supporting layer, or to hold up sagging muscle and fat or lift hypertrophied structures lying beneath it. The second party of the answer lies in the increase in neck surface area that occurs when deep neck contour is improved. Improving neck contour by removing excess pre-platysmal fat when present, excising redundant subplatysmal fat and performing other deep layer manoeuvres as indicated, followed by tightening a lax platysma will result in a depended cervicomental angle, a longer curvilinear distance from the mentum to the sternal notch, and a more concave and geometrically larger and longer neck surface. When the neck skin is re-draped and redistributed over the deeper, more concave surface, ‘excess’ skin is absorbed and none need to be removed. These simple but not intuitive or immediately obvious facts underlie the reason that skin excision need not be performed in patients with good skin quality and mild to moderate skin excess to obtain a good result.
Once the fact that increased neck surface area is produced by depending the cervicomental angle is acknowledged and accepted it becomes clear why it is counterproductive to excise any skin from the submental incision as this can create a ‘bow-string’ effect and actually blunt the cervicomental angle. The submental skin incision is used for access to the neck only in a properly performed neck lift, and if skin excision is necessary it is more practically, effectively and logically removed from the postauricular area.
There is a limit to the amount of neck skin that can be absorbed and managed in this manner, however, and an isolated neck lift performed through a submental incision only is typically best for male patients and younger women with mild to moderate skin excess, good skin elasticity and minimal or modest ageing in the mid face, cheek and jowl.
NECK LIFT WITH A CHIN IMPLANT
The difference between the presence of poor neck contour and microgenia is commonly misunderstood, and it is a common misconception that placement of a chin implant improves neck contour. A chin implant is a treatment for microgenia – not a poor neckline – and the presence or absence of microgenia and the need for a chin implant is a cephalometric determination that is independent of the condition of the neck. Placement of a chin implant when microgenia is not present is a conceptual and artistic error that will create unnatural appearances.
When true microgenia is present, however, placing a chin implant in combination with a neck lift will produce a more harmonious and balanced profile and a more aesthetic and attractive cervicofacial profile.
‘EXTENDED’ NECK LIFT AND NECK LIFT WITH FACELIFT
If a significant amount of redundant skin is present, it must be excised to obtain the best result, and in such situations it is most logically and effectively excised in the postauricular areas using periauricular skin incisions. Skin excision from the submental incision is conceptually flawed and will actually degrade neck contour rather than improve it, and skin excision using large midline Z-plasties will result in a poorly concealed scar, and bizarre changes in beard hair inclination in men.
Skin excision can be combined with treatment of the neck through the submental incision as an ‘extended’or ‘long-scar’neck lift, or as part of a facelift procedure.
Practically speaking, most patients in need of a neck lift with skin excision also need a facelift as it is unusual to encounter patients with excess skin in the neck but not elsewhere on the face. This particularly true in women and it is aesthetically inappropriate to perform an isolated neck lift in most women who present for facial rejuvenation. Lifting only the neck but not the cheeks, jowls and jawline can create an unnatural and unfeminine appearance.
Combining a facelift with a neck lift is almost always the best approach to obtain a balanced, natural and harmonious rejuvenation of the female face, although not all patients will recognise or accept this.